Questioning Medicine: Overdiagnosis, Overtreating

Too often, testing causes harm without changing outcomes.

Andrew Buelt, DO, and Joe Weatherly, DO, are family medicine residents in St. Petersburg, Fla. Together, they co-host a monthly CME piece on Primary Care RAP and they co-produce the podcast Questioning Medicine, where they deconstruct issues confronting today's clinicians. In this guest blog, Weatherly gives his take on overdiagnosing and overtreating patients.

Progress in medicine approaches that of Moore's Law. Each generation is responsible for more and more data, more information. More criteria and diseases. More of the growing piles of research and global connectivity.

We can do more now than ever before with the help of tools. Things like electronic journals and blogs, social media and peer-to-peer knowledge sharing, or Free Open Access Medical Education (#FOAMed). These tools comprise a world of ever-growing resources for reasonable real-time education and communication to improve patient outcomes.

With this increase in knowledge and information sharing, overdiagnosing and overtreating have become real problems. There's been a doubling of the diagnosis of pulmonary embolisms with advances in CT resolution, but our therapies lag behind and there isn't the same rise in improved outcomes. Other topics of overdiagnosis include prediabetes, prehypertension, degenerative disk disease, and cancer.

A prediabetes diagnosis proves to be little more than a label that engenders the same treatment as full-blown diabetes. We lack therapies that show consistent reduction in MI, stroke, and all-cause mortality. Will this predisease label improve quality of life? Or rather increase anxiety, medications, and time spent at the doctor?

Unchanged Outcomes

Take prehypertension, for example. The data struggle to show a decrease in mortality or morbidity in mild hypertension (up to 159 SBP) in the average adult, when treated with our best medications for life (Diao et al.). We stand too firmly when telling the parents of a pediatric patient that we can "help them" by treating their child's prehypertension, when we don't have a single quality study showing benefit from the treatment of moderate hypertension in children (Thompson et al.).

Breast cancer screening represents a fantastic tool that can potentially avoid a cruel and too common cause of cancer-related death in women. It is what we use, but it's not good enough. If 2,000 women ages 50 to 59 have mammograms every year for 10 years, one to two will avoid a breast cancer death.

The U.S. healthcare system wasted $210 billion in 2009 on excess testing, prescriptions, and procedures. The overuse of antibiotics is one of the larger contributors to antibiotic-resistant infections, which were associated with 23,000 deaths in 2009. If we are better stewards, we may have money left to use on breast MRIs and other safer diagnostic or screening exams that could potentially remove more of the harm and improve the diagnostic power of our process.

If money were the only price to those who are tested for pulmonary embolism, prediabetes, degenerative disk disease, prehypertension, and cancer, it would be worth it. But the price is much more steep.

Screening Harms

One of the lesser discussed harms of the temporary label associated with each "abnormal" screening test is the risk of permanent harm. Many who participate in screening can be affected for life without benefit from the process. One study showed approximately 25% of men still worried too often about prostate cancer after having a negative biopsy.

Rather than the screening machine helping to ease the burden of concern and anxiety, these individuals now endure a never-ending cycle of appointments and testing, which were negative in this study.

If we were to discuss the facts with the patient prior to the ultrasound and state that a 50-year-old has less than 0.01% chance of a lethal cancer and that the ultrasound and subsequent workup is 99.99% unlikely to yield clinically relevant cancer, most would decline.

The harms of being screened, and then sampled, and then placed into routine follow-up do not compare with the harms of not finding an early stage cancer that was easily treated and quality and quantity of life preserved. But that isn't what we are talking about. That is never the comparison.

This isn't about big pharma, guidelines, making the decision for our patients, deterring screening exams, or changing what you do to a patient. It's about the discussion, the awareness. Seeing both sides to the screening concept so that you can present them both to your patient.

It's about empowering your patient to make the decision with the end in mind. This is how we do it in family medicine. This is how we make a difference. This is our procedure. We walk with them through the tough decisions, and when they choose, we strive to make screening as safe as possible for them.

Reach us on Twitter @MedQuestioning (Dr. Joe Weatherly) and @AndrewBuelt (Dr. Andrew Buelt), or email us at QuestioningMedicine@gmail.com. Listen to our podcast to hear more topics we question.

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